Minnesota s Co-Occurring State Incentive Grant (COSIG) Lessons Learned: A Preliminary Report

Transcription

1 Minnesota s Co-Occurring State Incentive Grant (COSIG) Lessons Learned: A Preliminary Report Minnesota Department of Human Services Chemical and Mental Health Services Administration 1

2 Grant title: Minnesota Co-Occurring State Incentive Grant Grant number: TI18386 Minnesota Department of Human Services Project Director: Cynthia Godin Adult Mental Health Division 5 Cedar Street St. Paul, Minnesota cynthia.godin@state.mn.us Phone: Fax: Mailing address: P.O. Box St. Paul, MN

3 Integrated treatment, as a set of principles and practices, has been shown to improve recovery among individuals with co-occurring mental illness and substance use disorders (SAMHSA, 2). In 6 the Substance Abuse and Mental Health Services Administration (SAMHSA) awarded a $3.35 million grant to the Minnesota Department of Human Services to address infrastructure development and clinical capacity gaps within the mental health and chemical dependency treatment service system related to the successful treatment outcomes for persons with a co-occurring mental illness and substance use disorder. This report is a preliminary summary of the COSIG initiative and activities for the first three years of the grant. A final comprehensive evaluation report, including an analysis of Minnesota Medicaid claims data for persons receiving treatment for a co-occurring mental illness and substance use disorder, will be submitted to SAMHSA in September 11. The goals of Minnesota s Co-Occurring State Incentive Grant (COSIG) were to: Increase screening and assessment for co-occurring disorders Define competency standards for clinicians who want to provide integrated treatment Build networks between mental health and substance use providers Explore options to finance services for co-occurring disorders Share information on co-occurring disorders and integrated treatment through publications, newsletters and electronic news updates Mental health and chemical dependency outpatient treatment demonstration sites The COSIG initiative included an initial group of fourteen outpatient certified Rule 29 mental health centers who were also licensed as Rule 31 chemical dependency treatment programs. Most of the demonstration sites provided mental health and chemical dependency treatment services within the same building, while maintaining separate administrative and clinical organizational staffing structures, medical records, and distinct and separate policy and procedure manuals. Also included in the original demonstration sites were four tribal behavioral health clinics and two State Department of Corrections facilities with internal substance abuse programming. The sites progressed through several steps in their implementation of integrated treatment for cooccurring disorders: Participation in an assessment of their level of co-occurring services at the beginning of the project and two years following project implementation; Designation of an implementation leader to champion and oversee the agency s work plan with an implementation group and administrative support; Engagement of external stakeholders to provide feedback and help identify opportunities to maximize comprehensiveness of services throughout the service delivery system; Formation of an internal steering committee comprised of the implementation group and stakeholders to monitor and facilitate progress and incorporate stakeholder input; Development of an agency-specific work plan with identified timelines and responsible parties; Provision of staff time to participate in training, technical assistance, and consultation; Implementation of screening and assessment instruments that are valid and reliable for the treatment population; Work on improvements to documentation of integrated services and agency policies and procedures; 3

4 Provision of data on services and outcomes for persons with co-occurring disorders to monitor progress of integration. The participating outpatient programs also focused on integrating clinical practices in the treatment for co-occurring disorders, including use of the following specific treatment strategies: Standardized screening to determine the likelihood of co-occurring mental illness and substance use disorders Person-centered and empathic engagement strategies based on client readiness for change Integrated assessment of mental illness and substance use disorders, including the interaction of the disorders Stage-wise treatment corresponding to the person s readiness for change on each disorder Engagement of recovery supports such as self-help, peer-run supports and family involvement Minnesota s COSIG project compares favorably on integration of treatment to other states that received COSIG grants. Integration was measured using extensive, standardized assessment scales called the Dual Diagnosis Capability in Addiction Treatment (DDCAT) and the Dual Diagnosis Capability in Mental Health Treatment (DDCMHT) Indexes. As defined by these scales, Alcohol- Only Services (AOS) or Mental Health-Only Services (MHOS) programs cannot accommodate individuals with co-occurring disorders, no matter how stable the other disorder; Dual Diagnosis Capable (DDC) programs have a primary focus on one disorder but are capable of treating individuals who have relatively stable co-occurring problems; and Dual Diagnosis Enhanced (DDE) programs are able to treat individuals who have relatively unstable or more severe co-occurring disorders. Minnesota s programs were assessed at the beginning of the project and two years later after they had received training and technical assistance from the project. As shown in the following charts, a substantially higher percentage of Minnesota programs reached the levels of DDC and DDE, and fewer remained at the AOS/MHOS levels, than in other states in the nation. National distribution of program Dual Diagnosis Capability in AddictionTreatment, Time 1 (n=174) DDC 19% DDE 1% Minnesota distribution of program Dual Diagnosis Capability in Addiction Treatment, Time 1 (n=13) DDC 15% DDE % AOS % AOS 85% 4

5 National distribution of program Dual Diagnosis Capability in Addiction Treatment, Time 2 (n=96) Minnesota distribution of program Dual Diagnosis Capability in Addiction Treatment, Time 2 (n=12) DDE 1% DDE 8% AOS 8% DDC 46% AOS 53% DDC 84% National distribution of program Dual Diagnosis Capability in Mental Health Treatment, Time 2 (n=96) DDE 1% Minnesota distribution of program Dual Diagnosis Capability in Mental Health Treatment, Time 2 (n=12) DDE % DDC 31% MHOS 68% DDC 67% MHOS 33% The programs that reached at least a Dual Diagnosis Capability standing in September 9 were: Substance use treatment programs: African American Family Services, Inc. (Minneapolis) Central Minnesota Chemical Dependency Services (Buffalo) Fond du Lac Band of Superior Chippewa Tagawii Outpatient Chemical Health Program (Cloquet) Human Services Incorporated Adult Community Options Outpatient Program (Stillwater) Lakeland Mental Health Center Chemical Health Services (Fergus Falls) Neighborhood Counseling Center Chemical Dependency Outpatient Services of Wadena (Wadena) Northland Recovery Center Outpatient Program (Grand Rapids) Tubman-Chrysalis Co-Occurring Disorders Program (Minneapolis) Zumbro Valley Recovery Partners (Rochester) 5

6 Mental health treatment programs: Central Minnesota Mental Health Center (Buffalo) Chrysalis-Tubman Family Alliance (Minneapolis) Fond du Lac Band of Superior Chippewa Mental Health Services (Cloquet) Hiawatha Valley Mental Health Center (Winona) Human Services Incorporated Adult Mental Health Day Treatment Program (Oakdale) Lakeland Mental Health Center (Fergus Falls) Neighborhood Counseling Center of Wadena Inc. Outpatient Mental Health Services (Wadena) Northland Counseling Center, Inc. Outpatient Mental Health Clinic (Grand Rapids) Zumbro Valley Mental Health Center Outpatient Psychotherapy Services (Rochester) Minnesota Correctional Facility Programs: Atlantis Chemical Dependency Program (Stillwater State Prison) Changing PATHS Chemical Dependency Treatment (Shakopee State Prison) Mental health inpatient treatment demonstration sites As part of the effort to establish a continuum of care for co-occurring treatment services in Minnesota, grant activities focused on hospital-based mental health treatment and improving services for persons with a co-occurring substance use disorder. Using principles of Integrated Dual Disorder Treatment (IDDT), six psychiatric hospitals participated in a transformative change process by looking at clinical protocols and workforce competencies. The following six psychiatric hospitals participated: CentraCare Health System/St. Cloud Hospital (St. Cloud) HealthEast/Regions Hospital, units 4 and 7 (St. Paul) Hennepin County Medical Center (Minneapolis) MN Department of Human Services, State Operated Services, Anoka Metro Regional Treatment Center, unit D (Anoka) MN Department of Human Services, State Operated Services, St. Peter Community Behavioral Health Hospital (St. Peter) St. Joseph Hospital (St. Paul) These hospital psychiatric units followed steps in the implementation process similar to those of the outpatient programs. These activities included: Participation in an assessment of their level of co-occurring services; Designation of an implementation leader to champion and oversee the unit s work plan with an implementation group and administrative support; Formation of an internal steering committee comprised of the implementation group and stakeholders to monitor and facilitate progress and incorporate stakeholder input; Development of a work plan with identified timelines and responsible parties; Provision of staff time to participate in training, technical assistance, and consultation; Work on improvements to documentation of integrated services and unit policies and procedures to support provision of integrated treatment within hospital practices; Implementation of screening and assessment instruments that are valid and reliable for the treatment population; Review of available data on services and outcomes for persons with co-occurring disorders to monitor progress of integration. 6

7 Similar to delivery of integrated treatment in outpatient settings, the specific clinical practices involved in integrated treatment in a hospital include: Screening individuals admitted to the psychiatric program for substance use disorders; Conducting integrated assessments for co-occurring disorders, including how the disorders interact; Using stage-wise treatment interventions that match the person s readiness to change on each disorder; Planning for discharge with greater communication with and continuity of care to the next program or support setting. Providing integrated treatment of substance use disorders within a hospital psychiatric unit creates unique opportunities and challenges: Connecting treatment to patients personal recovery goals; Balancing the need for safety with the person s treatment choices based on their goals, readiness for change, preferences, priorities, and values. Addressing co-occurring disorders to the extent possible based on a combination of patient factors such as symptom acuity and readiness for change and hospital factors such as anticipated length of stay and availability of chemical dependency treatment in the hospital or network. Motivational interviewing training project A major effort of the Minnesota COSIG project was to increase skill levels of the behavioral health workforce in the essential practice of motivational interviewing (MI). MI is an evidence-based clinical practice that has demonstrated effectiveness in treating individuals with co-occurring disorders. MI pioneers Rollnick and Miller define the technique as a directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence. (Rollnick & Miller 1995). MI facilitates change in behavioral health issues such as smoking, substance use disorders, and mental illness, as well as in the behavioral components of medical problems such as diabetes, obesity and hypertension. Clinicians at Minnesota demonstration COSIG sites received twelve hours of classroom MI instruction, followed by monthly instructor-led classes using a manual developed by the state. Clinicians were also offered the opportunity to submit an audiotape for review, which was coded using a standardized code. In addition to subsidizing provider trainings, the project accomplished the following: Generation of 13 MI trainers, 9 of whom are members of the national Motivational Interviewing Network of Trainers (MINT) The development of a standard Minnesota MI curriculum that was used for the introductory 13- hour training The creation of an 8-session skills development practice manual to be used as a follow-up to the 13-hour training Training of 216 chemical and mental health counselors from the 12 COSIG sites on MI, with follow-up MI skills development practice classes and MITI coding Training of staff from an additional 26 mental and chemical health agencies in a MI Phase II project that focused on MI Skills Development Practice Classes. 7

8 != strongly disagree 5=strongly agree Outcomes of the Minnesota COSIG project In addition to the program integration data described earlier, the Minnesota COSIG project collected two other types of data to measure its success. One type of data was on client satisfaction with the four COSIG agencies that participated in the one-year project extension. Clients completed anonymous surveys that included both standardized questions and space for client comments. The graph below shows that client satisfaction, both with their functioning and on agency services, was high at all survey times (with 1 being the lowest satisfaction rating and 5 the highest); ratings did not vary across questions or agencies Time 1 Time 2 Time Client satisfaction T1-T4 Averages across agencies Total satisfaction n=13 n=78 n=73 n=72 Personal functioning n=13 n=78 n=73 n=72 Average across all 4 sites Services provided n=13 n=78 n=73 n=72 Similarly, client satisfaction data collected at one of the participating hospitals showed high satisfaction levels each month of their survey, on which 1 represented the lowest satisfaction rating and 4 the highest. Average satisfaction ratings across time for dual diagnosis (DD) and mental illness-only (MI) clients MI DD. Mar Apr May June July Aug Sep Oct Nov Dec Jan 8

9 Also informative are the comments that clients wrote on the surveys. A representative selection is included here: This is my 8th treatment but first time I ever worked on both issues and learned how they interact. I have 35 years of drug abuse, and mental health problems since I feel I am now getting the help that I need. I love [this program]! I have had separate treatments for mental health (cognitive behavioral therapy intensive) and for alcohol dependency (outpatient & inpatient), but both were lacking because I am dual diagnosis. I am so glad that [this agency] offers this program! The treatment is unique and beneficial to anyone with a dual diagnosis. This group and counselors are very supportive. I get help with my mental illness and sobriety I can't get anywhere else. Being here has been absolutely transformative. Especially in light of all the times I've been in conventional therapy. I feel "all of a piece" as my insides match my outsides. My symptoms and history play out in a diagnosable and treatable pattern. I am not afraid of it. This diagnosis explains some things I've done for which I had felt excruciating shame and guilt. This burden has been lifted from me by knowing the truth. Treatment here has been far more effective because the focus is on me, not an illness. I feel validated and this has given me the strength and understanding to accept my life and to navigate through challenges that may occur. I am growing both mentally and spiritually. I am starting to love me! I think the integration of addiction and mental illness is imperative to my healing. I have learned the strong correlation between emotions and use. The Dialectical Behavioral Therapy (DBT) skills taught here are invaluable now and forever. I am VERY grateful for the opportunity to recover here. It was interesting to see how they affect each other. It talks about both mental illness and addiction. I've only done one or the other in the past. It s opened my eyes to the importance of being clean and sober for my mental health. I am impressed with the staff and feel they have been extremely helpful and supportive to me and my family as well. I've been to other treatments but this is the first one I've actually been successful at and I believe it is because of the staff, the length and the content of the topics and material introduced to me in the groups as well as the group size. This treatment has been the best treatment I have ever been through. I have done inpatient and outpatient treatment and this one has been the most effective. Dialectical Behavioral Therapy (DBT) skills have been a great thing to be able to learn. Also learning that my feelings are very important to reconcile while in recovery because they have a lot to do with why I use. DBT helps me identify how I feel and ways to cope. 9

10 The remaining type of data, called the Co-Occurring Measures (COMs), tracked changes in the proportions of clients in the outpatient programs that were screened, assessed, diagnosed, and treated for co-occurring disorders during the COSIG. Data from three quarters of the COMs, shown on the following page, indicate that on most of the measures performance varied little across time. For example, screening rates started out high at 77% and remained close to that figure by the last quarter (73%). However, on two of the COMs substantial improvement was documented. Of those individuals who were diagnosed with co-occurring disorders, the proportion who were treated for both rose from 69% in quarter 2 to % by the 4 th quarter. In addition, of those treated for cooccurring disorders, the proportion treated with the highest level of integration of services rose from 17% to 26%. These data suggest that the goal of improving the screening, assessment and treatment of co-occurring disorders was met during the COSIG. 1

11 % of treated for both CODs percent of population % of dx with CODs percent of population % of assessed for CODs percent of population % of screened for CODS Screening, assessment, diagnosis and treatment data from 13 demonstration sites Qtr 2: Oct 1-Dec 31, 8, n=732; Qtr 3: Jan 1-March 3, 9, n=742; Qtr 4: Apr 1-June 3, 9, n=7 Screened for co-occurring disorders Qtr 2 Qtr 3 Qtr 4 2 Screened positive for co-occurring disorders Qtr 2 Qtr 3 Qtr 4 Assessed for co-occurring disorders Diagnosed with co-occurring disorders Qtr 2 Qtr 3 Qtr 4 4 Qtr 2 Qtr 3 Qtr 4 Total diagnosed with co-occurring disorders Qtr 2 Qtr 3 Qtr 4 Treated for both co-occurring disorders Qtr 2 Qtr 3 Qtr Treatment arrangement for co-occurring disorders from lowest (minimal coordination) to highest (integration) minimal coordination consultation collaboration integration Qtr 2 Qtr 3 Qtr

12 Untreated or unsuccessfully treated co-occurring mental illness and substance use disorders contributes to major social problems in America, including poverty, increased hospitalization and use of emergency care, inadequate access to health care for routine and chronic medical conditions, and crime (Mueser et al, (3). In Minnesota, transforming the way treatment is provided for cooccurring disorders within its separate treatment systems of mental health or chemical dependency care is imperative. Each separate treatment system, whether mental health treatment or chemical dependency treatment, can continue to improve its capacity to screen and refer or screen, assess and treat co-occurring disorders. Next steps for Minnesota Transforming the way services are provided when an individual seeks treatment for a co-occurring mental illness and substance use disorder takes time. Working within and across separate treatment systems that have different funding, regulatory, staffing and licensure requirements means that the state must make a long-term work commitment to lasting and sustainable systemic change. Next steps for Minnesota in its transformation of co-occurring services will be to: Evaluate the need for administrative rule or statute changes Rule and statute for mental health services do not require the use of Integrated Dual Disorder Treatment strategies Identify clinician workforce competencies needed to treat co-occurring disorders Competencies have been written but are not a required component of licensure Partner with higher education institutions to support clinician workforce Universities and colleges play an important role in the development of our workforce Develop standardized protocols for co-occurring services Separate licensing for mental health and chemical dependency services means providers must meet two different standards Add co-occurring service protocols to standard contract language Screening protocols have been added to managed care contracts but more can be done Identify needed changes in payment rates Outpatient mental health services under Minnesota Health Care Programs will soon allow for an extended diagnostic assessment for persons with co-occurring substance use Change the way data is collected, reported and evaluated for co-occurring services Data is reported separately for mental health and chemical dependency, making it difficult to make informed policy decisions on co-occurring service delivery Develop a state technical assistance website to disseminate information and improve communication More information should be available to assist interested persons and stakeholders on the progress of cooccurring service development in Minnesota Develop a program certification process to recognize programs with co-occurring capability A co-occurring program designation would help individuals to know where to seek co-occurring treatment services 12